Christer Mjåset – Neurosurgeon and the Vice President of the Norwegian Medical Association

I am a neurosurgeon, and I’m here to tell you today that people like me need your help. And in a few moments, I will tell you how.

But first let me start off by telling you about the patient of mine. This was a woman in her 50s. She was in generally good shape but she had been in and out of hospital a few times due to curative breast cancer treatment.

Now she had gotten a prolapse from a cervical disc giving her radiating pain of a tense kind out into the right arm. Looking at her MRI before the consultation I decided to suggest an operation. Now operations like these are standardized and they’re quick but they carry a certain risk. You make an incision right here and you dissect carefully past the trachea, esophagus and you try not to cut into the internal carotid artery.

Then you bring in the microscope and you carefully remove the disc and the prolapse in the nerve root canal without damaging the cord and the nerve root lying only millimeters underneath. A worst-case scenario is the damage to the cord which can result in paralysis from the neck down.

Explaining this to the patient she felt silent and after a few moments she uttered a few very decisive words for me and for her: “Doctor, is this really necessary?”

And you know what I realized right there and then: it was not. In fact, when I get patients like this woman, I tend to advise not to operate.

So what made me do it this time? Well, you see this prolapse was so delicate. I could practically see myself pulling it out of the nerve root canal before she entered the consultation room. I have to admit it I wanted to operate her. I’d love to operate her. Operating like this is after all the most fun part of my job. I think you can relate to this feeling.

My architect neighbor says he loves to just sit and draw and design houses. He’d rather do that all day, then talk to the person, the client paying for the house, that might even give them restrictions on what to do. But like every architect, every surgeon needs to look the patient in the eye and together with the patient they need to decide on what is best for the person having the operation. And that might sound easy but let’s look at some statistics.

The tonsils are the two lumps in the back of your throat. They can be removed surgically and that’s called a tonsillectomy. This chart shows the operation rate of tonsillectomies in Norway in different regions. What might strike you is that there is twice the chance that your kid — because this is for only children — will get the tonsillectomy in Finnmark than in Trondheim. The indication in both regions are the same. There should be no difference at risks.

Here’s another chart. The meniscus have stabilized the knee and can be torn or fragmented acutely typically during sports like soccer. What you see here is the operation rate for this condition, and you see that the operation rate in Møre og Romsdal is five times the operation rate in Stavanger. Five times?

How can this be? Do the soccer players in Møre og Romsdal play more dirty than elsewhere in the country? Probably not.

I’ve added some information now. What you see now is the procedures performed in public hospitals are light-blue, the one in private clinics is light green there. There is a lot activity on in the private clinics in Møre og Romsdal; isn’t there?

What does this indicate? Possible economic motivation to treat the patients, and there’s more. Recent research has shown that the difference of treatment effect between regular physical therapy and operations for the knee, there is no difference. Meaning, that most of the procedures performed on the chart I’ve just shown could have been avoided even in Stavanger.

So what am I trying to tell you here? Even though most indications for treatments in the world are standardized, there is a lot of unnecessary variation of treatment decisions, especially in the Western world. Some people are not getting the treatment that they need, but an even greater portion of you are being over-treated. Doctor, is this really necessary? I’ve only heard that question once in my career. My colleagues say they never heard these words from a patient.